1255732962 NPI number — EXODUS FOUNDATION

Table of content: (NPI 1255732962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255732962 NPI number — EXODUS FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXODUS FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255732962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9808 VENICE BLVD STE 700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90232-6824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-945-3350
Provider Business Mailing Address Fax Number:
310-840-7023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12021 S WILMINGTON AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR IC1-IC7
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90059-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-295-5916
Provider Business Practice Location Address Fax Number:
562-295-5965
Provider Enumeration Date:
09/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SKOROHOD
Authorized Official First Name:
LEEANN
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP OPERATIONS
Authorized Official Telephone Number:
310-945-3350

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7890 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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